New Jersey Office of Attorney GeneralDivision of Consumer Affairs

Legalized Games of Chance Control Commission124 Halsey Street, 6th Floor, P.O. Box 46000

Newark, New Jersey 07101(973) 273-8000

Instructions for Filing the Raffle Report of Operations PursuanttoN.J.A.C.13:47-9.1,licenseesmustfileareportofoperationswiththeLegalizedGamesofChanceControlCommissionnolaterthanthe15thdayofthecalendarmonthimmediatelyfollowingthecalendarmonthinwhichthelicensedactivitywasheld,operatedorconducted.

YoumustdownloadthisreportandcompleteALLoftheentriesforeachoccasion(s)relatingtotheconductofallraffles,exceptforinstantrafflegamesandcarnivalgamesandwheels.Oncecompleted,amember/officermustcertifythathe/shehasreviewedthereportandthattheinformationprovidedistrue,accurateandcomplete.Thiswillrequirethepersontostatehis/hernameandtitle,andthatpersonmustcompletetheinformationonpage3andhavethereportnotarized.

TheRaffleReportofOperationsfortheconductofoff-premises50/50ormerchandiserafflesistobeaccompaniedwithasampleticket.ReportsaretobemailedtoLegalizedGamesofChanceControlCommission,P.O.Box46000,Newark,NewJersey07101,oremailedtoAskGames@dca.njoag.gov.

Itisrecommendedthatyoumaintainacopyofallreportsaspartoftheorganization’srecords.

New Jersey Office of Attorney GeneralDivision of Consumer Affairs

Legalized Games of Chance Control Commission124 Halsey Street, 6th Floor, P.O. Box 46000

Newark, New Jersey 07101(973) 273-8000

Raffle Report of Operations

Please print clearly.Identificationnumber (format ###-##-#####) _____________________

Municipality______________________________________ Licensenumber______________________

Nameoflicensee_____________________________________________________________________________Organization

___________________________________________________________________________________________Streetaddress City State ZIPcode

Locationofgames____________________________________________________________________________

This report, as required byN.J.S.A. 5:8-37 andN.J.A.C. 13:47-9,must befiledwith theLegalizedGamesofChanceControlCommissionnolaterthanthe15thdayofthemonthfollowingtheconductofthegame(s)ofchance.

Occasion 1 Date ____________________Time_____________________ Typeofraffle______________

1.Numberofticketssold ___________ 4.Costofprizes $__________ Typeofprize(s)_____________2.Ticketprice $___________ 5.Supplies/Equipmentcost $__________3.Grossreceipts $___________ 6.Otherexpenses $__________

7.Totalexpenses $__________ 8.Netproceeds $_________

Occasion 2 Date ____________________Time_____________________ Typeofraffle______________1.Numberofticketssold ___________ 4.Costofprizes $__________ Typeofprize(s)_____________2.Ticketprice $___________ 5.Supplies/Equipmentcost $__________3.Grossreceipts $___________ 6.Otherexpenses $__________

7.Totalexpenses $__________ 8.Netproceeds $_________

Occasion 3 Date ____________________Time_____________________ Typeofraffle______________1.Numberofticketssold ___________ 4.Costofprizes $__________ Typeofprize(s)_____________2.Ticketprice $___________ 5.Supplies/Equipmentcost $__________3.Grossreceipts $___________ 6.Otherexpenses $__________

7.Totalexpenses $__________ 8.Netproceeds $_________

Occasion 4 Date ____________________Time_____________________ Typeofraffle______________1.Numberofticketssold ___________ 4.Costofprizes $__________ Typeofprize(s)_____________2.Ticketprice $___________ 5.Supplies/Equipmentcost $__________3.Grossreceipts $___________ 6.Otherexpenses $__________

7.Totalexpenses $__________ 8.Netproceeds $_________

Occasion 5 Date ____________________Time_____________________ Typeofraffle______________1.Numberofticketssold ___________ 4.Costofprizes $__________ Typeofprize(s)_____________2.Ticketprice $___________ 5.Supplies/Equipmentcost $__________3.Grossreceipts $___________ 6.Otherexpenses $__________

7.Totalexpenses $__________ 8.Netproceeds $_________

Occasion 6 Date _______ Time_________ Typeofraffle _________

1.Numberofticketssold ___________ 4.Costofprizes $__________ Typeofprize(s)_____________2.Ticketprice $___________ 5.Supplies/Equipmentcost $__________3.Grossreceipts $___________ 6.Otherexpenses $__________(Ifneeded,attachseparatesheet)

7.Totalexpenses $__________ 8.Netproceeds $_________

Totalnumberofoccasions.................................. _________Totalnumberofticketssold(1-6combined)...... _________ Priceoftickets..................................................... $ ________ Totalgrossproceeds(1-6combined).................. $ ________ Totalexpenses(1-6combined)........................... $ ________ Totalnetproceeds(1-6combined)...................... $ ________

Date

Schedule of Expenses

Description Checknumber Amount

Date

Utilization of Net Proceeds

Description Checknumber Amount

Name

Bank

Addresswherebalanceisdeposited Accountnumber

Name

Person Responsible for Use of Proceeds

Address Telephonenumber(includeareacode)

Icertifythatallofthestatementsonthisreportofoperationsaretrue,accurateandcomplete.Iamawarethatifanyoftheforegoingstatementsarewillfullyfalse,Iamsubjecttopunishment.

N.J.S.A.5:8-37“Itshallbethedutyofeachlicenseetomaintainandkeepsuchbooksandrecordsasmaybenecessarytosubstantiatetheparticularsofeachsuchreport.”

I certify that I have reviewed this report and that the informationon this report of operations is true,accurateandcomplete.Iamawarethatifanyoftheforegoingstatementsarewillfullyfalse,Iamsubjecttopunishment.

I certify by placing a check in this box, that I have reviewed the report and that the information provided is true, accurate and complete.

Youmuststateyournameandtitlebelow.Reportsthatarenotproperlycertifiedwillbeemailedback.

_______________________________________ __________________________________________Nameandtitleofofficer(pleaseprint) Signatureofofficer

Swornandsubscribedtobeforemethis__________dayof ______________________ ,____________

__________________________________________ NameofNotaryPublic(pleaseprint)__________________________________________SignatureofNotaryPublic

MonthYear Affix Seal Here

Form LGCCC 8R-A (Rev. 4/6/16)

Prizes Offered or AwardedPleaselisttheprizesofferedorawardedandtheirrespectiveretailvalues.

PrizesOfferedorAwarded RetailValue PrizesOfferedorAwarded RetailValue